Probable Questions - General Medicine End Posting Exam

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import ListFlowable, ListItem

OUTPUT = "/home/daytona/workspace/medicine-study-guide/Medicine_EndPosting_StudyGuide.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2*cm,
    leftMargin=2*cm,
    topMargin=2.5*cm,
    bottomMargin=2*cm,
    title="General Medicine End Posting - Study Guide",
    author="Orris AI"
)

# ── COLOUR PALETTE ──────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1a3a5c")
MID_BLUE    = colors.HexColor("#2563a8")
LIGHT_BLUE  = colors.HexColor("#dbeafe")
ACCENT_RED  = colors.HexColor("#b91c1c")
GOLD        = colors.HexColor("#b45309")
GREEN       = colors.HexColor("#15803d")
LIGHT_GREEN = colors.HexColor("#dcfce7")
LIGHT_GOLD  = colors.HexColor("#fef3c7")
LIGHT_RED   = colors.HexColor("#fee2e2")
GREY_BG     = colors.HexColor("#f1f5f9")
DARK_GREY   = colors.HexColor("#334155")
WHITE       = colors.white

# ── STYLES ───────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

cover_title = ParagraphStyle("cover_title",
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cover_sub = ParagraphStyle("cover_sub",
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cover_note = ParagraphStyle("cover_note",
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chapter_title = ParagraphStyle("chapter_title",
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section_head = ParagraphStyle("section_head",
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subsection_head = ParagraphStyle("subsection_head",
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body_text = ParagraphStyle("body_text",
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bullet_text = ParagraphStyle("bullet_text",
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sub_bullet = ParagraphStyle("sub_bullet",
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bold_label = ParagraphStyle("bold_label",
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highlight_box = ParagraphStyle("highlight_box",
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toc_entry = ParagraphStyle("toc_entry",
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toc_head = ParagraphStyle("toc_head",
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    spaceAfter=5, leading=15)

story = []

# ════════════════════════════════════════════════════════════════════════════
# HELPER FUNCTIONS
# ════════════════════════════════════════════════════════════════════════════

def chapter_banner(title, subtitle=""):
    """Coloured banner for chapter headers."""
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def info_box(text, bg=LIGHT_BLUE, border=MID_BLUE):
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def warn_box(text):
    return info_box("⭐ " + text, bg=LIGHT_GOLD, border=GOLD)

def key_box(text):
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def red_box(text):
    return info_box("⚠ " + text, bg=LIGHT_RED, border=ACCENT_RED)

def b(text): return f"<b>{text}</b>"
def i(text): return f"<i>{text}</i>"
def br(): return Spacer(1, 0.3*cm)
def hline(): return HRFlowable(width="100%", thickness=0.5,
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def two_col_table(left_items, right_items, left_head="", right_head=""):
    """Two-column comparison table."""
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    if left_head or right_head:
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    if left_head or right_head:
        style += [("BACKGROUND",(0,0),(-1,0), DARK_BLUE)]
    t.setStyle(TableStyle(style))
    return t

def simple_table(headers, rows, col_widths=None):
    """Generic styled table."""
    if col_widths is None:
        col_widths = [17*cm / len(headers)] * len(headers)
    data = [[Paragraph(b(h), ParagraphStyle("th", fontName="Helvetica-Bold",
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        data.append([Paragraph(str(c), ParagraphStyle("td", fontName="Helvetica",
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    t = Table(data, colWidths=col_widths)
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0),(-1, 0), DARK_BLUE),
        ("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, GREY_BG]),
        ("GRID",         (0,0),(-1,-1), 0.5, colors.HexColor("#94a3b8")),
        ("TOPPADDING",   (0,0),(-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
        ("LEFTPADDING",  (0,0),(-1,-1), 6),
    ]))
    return t

def bp(text):   return Paragraph("• " + text, bullet_text)
def sbp(text):  return Paragraph("  - " + text, sub_bullet)
def head(text): return Paragraph(text, section_head)
def subh(text): return Paragraph(text, subsection_head)

# ════════════════════════════════════════════════════════════════════════════
# COVER PAGE
# ════════════════════════════════════════════════════════════════════════════

cover_bg = Table([
    [Paragraph("GENERAL MEDICINE", cover_title)],
    [Paragraph("End Posting Exam", cover_sub)],
    [Paragraph("Complete Study Guide", cover_sub)],
    [Spacer(1, 0.5*cm)],
    [Paragraph("Phase 3 · Part 1 · 2023 Batch", cover_note)],
    [Spacer(1, 0.3*cm)],
    [Paragraph("Govt. Medical College, Manjeri", cover_note)],
    [Spacer(1, 1*cm)],
    [Paragraph("Cardiology · Respiratory · Neurology · GI/Hepatology · Endocrine · Renal", cover_note)],
], colWidths=[17*cm])
cover_bg.setStyle(TableStyle([
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    ("RIGHTPADDING", (0,0),(-1,-1), 20),
]))
story.append(Spacer(1, 2*cm))
story.append(cover_bg)
story.append(Spacer(1, 1*cm))

notice_data = [
    [Paragraph(b("Exam Format"), ParagraphStyle("nf", fontName="Helvetica-Bold",
        fontSize=10, textColor=DARK_BLUE, leading=13)),
     Paragraph("Time: 1.5 hrs  |  Marks: 50  |  1 Essay (10m) + Short Essays (6m each) + Short Answers (2m each)",
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]
notice_t = Table(notice_data, colWidths=[4*cm, 13*cm])
notice_t.setStyle(TableStyle([
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    ("LEFTPADDING",(0,0),(-1,-1), 8),
]))
story.append(notice_t)
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# TABLE OF CONTENTS
# ════════════════════════════════════════════════════════════════════════════

story.append(Paragraph("Contents", ParagraphStyle("toc_main",
    fontName="Helvetica-Bold", fontSize=20, textColor=DARK_BLUE,
    spaceAfter=10, leading=24)))
story.append(hline())

toc_items = [
    ("SECTION 1", "CARDIOLOGY", [
        "1.1  Mitral Stenosis (Rheumatic)",
        "1.2  Aortic Regurgitation",
        "1.3  Aortic Stenosis",
        "1.4  Congestive Cardiac Failure",
        "1.5  Infective Endocarditis",
        "1.6  Cor Pulmonale",
        "1.7  Rheumatic Fever - Jones Criteria",
    ]),
    ("SECTION 2", "RESPIRATORY", [
        "2.1  Pulmonary Tuberculosis",
        "2.2  COPD",
        "2.3  Pleural Effusion",
        "2.4  Lung Consolidation vs Collapse",
        "2.5  Pneumothorax",
    ]),
    ("SECTION 3", "NEUROLOGY", [
        "3.1  UMN vs LMN Lesion",
        "3.2  Ischemic Stroke",
        "3.3  Lateral Medullary Syndrome",
        "3.4  Guillain-Barre Syndrome",
        "3.5  Aphasia vs Dysarthria",
        "3.6  Meningitis",
    ]),
    ("SECTION 4", "GI / HEPATOLOGY", [
        "4.1  Chronic Liver Disease - Clinical Diagnosis",
        "4.2  Jaundice - Evaluation",
        "4.3  Ascites & SAAG",
        "4.4  Hepatic Encephalopathy",
    ]),
    ("SECTION 5", "ENDOCRINE & RENAL", [
        "5.1  Hypothyroidism",
        "5.2  Diabetic Nephropathy",
        "5.3  Nephrotic vs Nephritic Syndrome",
        "5.4  Hypertensive Emergency",
    ]),
    ("SECTION 6", "CLINICAL SIGNS (SHORT ANSWERS)", [
        "JVP Waveform · S3 · Clubbing · Cyanosis",
        "Pulsus Paradoxus · Kussmaul's Sign · Cheyne-Stokes",
        "Babinski Sign · Plantar Response · Kernig's & Brudzinski's",
        "Flapping Tremor · Trousseau's · Chvostek's",
        "Osler's Nodes vs Janeway Lesions · Glasgow Coma Scale",
    ]),
]
for sec, sec_title, items in toc_items:
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        ParagraphStyle("toc_sec", fontName="Helvetica-Bold", fontSize=11,
            textColor=DARK_BLUE, spaceBefore=8, spaceAfter=2,
            leftIndent=0, leading=14)))
    for it in items:
        story.append(Paragraph(it, toc_entry))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 1 — CARDIOLOGY
# ════════════════════════════════════════════════════════════════════════════

story.append(chapter_banner("SECTION 1: CARDIOLOGY",
    "Mitral Stenosis · Aortic Regurgitation · Aortic Stenosis · CCF · IE · Cor Pulmonale"))
story.append(br())

# ── 1.1 MITRAL STENOSIS ───────────────────────────────────────────────────
story.append(head("1.1  Mitral Stenosis (Rheumatic)  ⭐⭐⭐"))
story.append(warn_box("HIGHEST PRIORITY - appeared in BOTH model papers. Expect this or a close variant as your Essay question."))
story.append(br())
story.append(subh("Most Probable Essay Vignette"))
story.append(info_box(
    "A 30-year-old female presents with progressive breathlessness, palpitations, and occasional hemoptysis. "
    "History of recurrent sore throat in childhood. Pulse 96/min irregular, BP 110/70 mmHg, "
    "apex beat not palpable, loud S1, opening snap, mid-diastolic murmur at apex.", GREY_BG, MID_BLUE))
story.append(br())
story.append(subh("a) Diagnosis & Differential Diagnosis"))
story.append(bp(b("Diagnosis:") + " Mitral Stenosis (Rheumatic)"))
story.append(bp(b("Differentials:") + " Mitral regurgitation, Left atrial myxoma, Austin Flint murmur of AR, Tricuspid stenosis"))
story.append(br())
story.append(subh("b) CVS Examination Findings"))
story.extend([
    bp(b("Inspection:") + " Mitral facies (malar flush), apex beat not visible"),
    bp(b("Palpation:") + " Tapping apex (palpable S1), parasternal heave (RVH), apical diastolic thrill"),
    bp(b("Auscultation:") + " Loud S1 + Opening Snap (OS) + Mid-diastolic rumble with presystolic accentuation"),
    sbp("Best heard: apex, left lateral decubitus, bell of stethoscope"),
    sbp("Graham Steell murmur: early diastolic at left sternal border if pulmonary hypertension"),
    bp(b("Signs of pulmonary HTN:") + " Loud P2, right parasternal heave, elevated JVP"),
])
story.append(br())
story.append(subh("c) Investigations"))
story.extend([
    bp(b("ECG:") + " P mitrale (bifid broad P in lead II), Atrial Fibrillation, RVH (right axis deviation)"),
    bp(b("CXR:") + " Straightening of left heart border, double right heart border (LA enlargement), Kerley B lines, upper lobe diversion"),
    bp(b("Echocardiography (2D + Doppler):") + " Gold standard - valve area (MVA <1.5 cm² = severe), pressure half time (PHT), Wilkins score for PTMC suitability"),
    bp(b("Cardiac catheterization:") + " If echo findings discrepant"),
])
story.append(br())
story.append(subh("d) Causes of Worsening (Decompensation)"))
story.extend([
    bp(b("Most common:") + " Onset of Atrial Fibrillation (loss of atrial kick → sudden rise in LA pressure)"),
    bp("Pregnancy (increased blood volume and HR)"),
    bp("Intercurrent infection / fever (increased metabolic demand)"),
    bp("Infective endocarditis"),
    bp("Anemia, hyperthyroidism"),
])
story.append(br())
story.append(key_box("Memory: MVA critical values: <2 cm² = significant, <1.5 cm² = severe, <1 cm² = very severe"))
story.append(br())
story.append(hline())

# ── 1.2 AORTIC REGURGITATION ──────────────────────────────────────────────
story.append(head("1.2  Aortic Regurgitation  ⭐⭐⭐"))
story.append(warn_box("Most probable 'NEW' essay topic - logically alternates with Mitral Stenosis."))
story.append(br())
story.append(subh("Peripheral Signs of AR (All named eponyms - exam favourite)"))
peripheral_ar = [
    ["Sign", "Description"],
    ["Corrigan's pulse", "Visible pulsation in neck (water-hammer pulse)"],
    ["De Musset's sign", "Head nodding with each heartbeat"],
    ["Quincke's sign", "Capillary pulsation at nail bed"],
    ["Duroziez's sign", "To-and-fro murmur over femoral artery with partial compression"],
    ["Traube's sign", "Pistol shot sound over femoral artery"],
    ["Müller's sign", "Pulsation of uvula"],
    ["Hill's sign", "Popliteal BP > brachial BP by >20 mmHg"],
    ["Lighthouse sign", "Flushing and blanching of forehead skin"],
]
t = simple_table(["Sign", "Description"], peripheral_ar[1:], [5*cm, 12*cm])
story.append(t)
story.append(br())
story.append(subh("CVS Examination Findings"))
story.extend([
    bp(b("Pulse:") + " Collapsing (water-hammer) - raise arm → feel more prominent"),
    bp(b("BP:") + " Wide pulse pressure (e.g. 160/40) - systolic high, diastolic low"),
    bp(b("Apex:") + " Displaced downward and outward (6th-7th ICS, anterior axillary line), hyperdynamic, heaving"),
    bp(b("Auscultation:") + " Early diastolic murmur (high-pitched, blowing) at 3rd ICS left sternal border (Erb's point)"),
    sbp("Accentuated by: patient sitting forward, deep expiration"),
    sbp("Austin Flint murmur: mid-diastolic rumble at apex (regurgitant jet vibrates anterior mitral leaflet)"),
    bp(b("S1:") + " Soft (early mitral valve closure); S2 soft or absent (A2)"),
])
story.append(br())
story.append(subh("Causes"))
story.extend([
    bp(b("Acute AR:") + " Infective endocarditis (most common cause of acute), aortic dissection, trauma"),
    bp(b("Chronic AR:") + " Rheumatic heart disease (most common in India), Marfan syndrome, ankylosing spondylitis, bicuspid aortic valve, syphilitic aortitis, hypertension"),
])
story.append(br())
story.append(hline())

# ── 1.3 AORTIC STENOSIS ───────────────────────────────────────────────────
story.append(head("1.3  Aortic Stenosis  ⭐⭐⭐"))
story.append(subh("Classic Triad - SAD"))
story.append(info_box(b("S")+"yncope  •  "+b("A")+"ngina  •  "+b("D")+"yspnea  (in order of appearance → increasing severity)", LIGHT_GREEN, GREEN))
story.append(br())
story.extend([
    bp(b("Pulse:") + " Pulsus parvus et tardus (slow rising, low volume, plateau pulse)"),
    bp(b("Apex:") + " Heaving, not displaced (pressure overload → concentric hypertrophy)"),
    bp(b("Thrill:") + " Systolic thrill in aortic area and carotids"),
    bp(b("Murmur:") + " Ejection systolic murmur, harsh, crescendo-decrescendo, 2nd ICS right sternal border, radiates to carotids"),
    bp(b("Severe AS signs:") + " Reversed split S2 (A2 delayed), S4 gallop (stiff LV), loss of A2"),
    bp(b("Investigations:") + " Echo (valve area by continuity equation: severe <1 cm², mean gradient >40 mmHg), ECG (LVH), CXR (post-stenotic dilatation of aorta)"),
    bp(b("Treatment:") + " Surgical AVR or TAVI (transcatheter); surgery indicated if symptomatic severe AS or asymptomatic with EF <50%"),
])
story.append(br())
story.append(hline())

# ── 1.4 CONGESTIVE CARDIAC FAILURE ────────────────────────────────────────
story.append(head("1.4  Congestive Cardiac Failure  ⭐⭐⭐"))
story.append(subh("Left vs Right Heart Failure"))
lhf = ["Dyspnea on exertion", "Orthopnea, PND", "Pulmonary edema", "Bibasal crackles",
       "S3 gallop (best at apex)", "Displaced apex beat", "Tachycardia, cold extremities"]
rhf = ["Raised JVP", "Pitting pedal edema (ankles to thighs)", "Hepatomegaly (tender, pulsatile)", "Ascites",
       "Sacral edema (bed-bound)", "Parasternal heave", "Kussmaul's sign (constrictive)"]
story.append(two_col_table(lhf, rhf, "Left Heart Failure", "Right Heart Failure"))
story.append(br())
story.append(subh("Pathophysiology of Orthopnea & PND"))
story.extend([
    bp(b("Orthopnea:") + " On lying flat → redistribution of blood from legs to pulmonary circulation → raised LA pressure → pulmonary congestion → breathlessness; relieved by sitting up"),
    bp(b("PND (Paroxysmal Nocturnal Dyspnea):") + " Same mechanism + reduced sympathetic tone during sleep + reabsorption of interstitial fluid → pulmonary edema at night; patient wakes up 1-2 hrs after sleeping, goes to window for air"),
])
story.append(br())
story.append(subh("Management (Pharmacological)"))
story.extend([
    bp(b("ACE inhibitors/ARB:") + " Reduce afterload and preload, improve survival (HFrEF EF <40%)"),
    bp(b("Beta-blockers:") + " Carvedilol, bisoprolol, metoprolol - reduce mortality, start low dose"),
    bp(b("Diuretics:") + " Furosemide (loop) - symptom relief; spironolactone/eplerenone (MRA) - mortality benefit"),
    bp(b("Digoxin:") + " Rate control in AF + HF; positive inotrope"),
    bp(b("SGLT2 inhibitors:") + " Empagliflozin, dapagliflozin - now first-line in HFrEF regardless of diabetes"),
    bp(b("ARNI:") + " Sacubitril/valsartan - superior to ACE inhibitor in HFrEF"),
])
story.append(br())
story.append(hline())

# ── 1.5 INFECTIVE ENDOCARDITIS ────────────────────────────────────────────
story.append(head("1.5  Infective Endocarditis  ⭐⭐"))
story.append(subh("Modified Duke Criteria"))
story.append(bp(b("MAJOR Criteria:")))
story.extend([
    sbp("Positive blood cultures: 2 separate sets with typical organisms (Strep viridans, Staph aureus, HACEK group)"),
    sbp("Echocardiographic evidence: vegetation, abscess, dehiscence of prosthetic valve, new valvular regurgitation"),
])
story.append(bp(b("MINOR Criteria:")))
story.extend([
    sbp("Predisposing condition (rheumatic valve disease, congenital HD, prosthetic valve, IV drug use)"),
    sbp("Fever > 38°C"),
    sbp("Vascular phenomena: septic arterial emboli, Janeway lesions (painless, palms/soles), conjunctival hemorrhage, intracranial hemorrhage"),
    sbp("Immunological phenomena: Osler's nodes (painful, fingers/toes), Roth spots (retina), glomerulonephritis, positive RF"),
    sbp("Microbiological: positive culture not meeting major criteria"),
])
story.append(br())
story.append(info_box(b("Diagnosis: ") + "2 Major  OR  1 Major + 3 Minor  OR  5 Minor criteria", LIGHT_GOLD, GOLD))
story.append(br())
story.append(subh("Peripheral Stigmata of IE"))
ie_signs = [
    ["Splinter hemorrhages", "Linear reddish-brown, nail beds, embolic"],
    ["Janeway lesions", "Painless erythematous macules, palms/soles, embolic"],
    ["Osler's nodes", "Painful, raised, finger/toe pads, immunological"],
    ["Roth spots", "Oval retinal hemorrhages with pale centre"],
    ["Clubbing", "Chronic IE"],
    ["Splenomegaly", "Immune activation + septic emboli"],
]
story.append(simple_table(["Sign", "Description"], ie_signs, [5*cm, 12*cm]))
story.append(br())
story.append(hline())

# ── 1.6 COR PULMONALE ────────────────────────────────────────────────────
story.append(head("1.6  Cor Pulmonale  ⭐⭐⭐"))
story.append(info_box(b("Definition: ") +
    "Right ventricular hypertrophy and/or failure secondary to pulmonary hypertension caused by diseases of the lung parenchyma, "
    "pulmonary vasculature, or chest wall — NOT due to left heart disease or congenital heart disease.", GREY_BG, MID_BLUE))
story.append(br())
story.extend([
    bp(b("Causes:") + " COPD (most common), pulmonary fibrosis, pulmonary embolism (chronic), kyphoscoliosis, OSA, primary pulmonary HTN"),
    bp(b("Symptoms:") + " Breathlessness, cyanosis, peripheral edema, fatigue"),
    bp(b("Signs:") + " Raised JVP with prominent 'a' wave (if sinus rhythm), parasternal heave (RVH), loud P2, TR murmur (pansystolic, louder on inspiration = Carvallo's sign), pedal edema"),
    bp(b("ECG:") + " P pulmonale (peaked P > 2.5mm in lead II), right axis deviation, RVH (R > S in V1), RBBB"),
    bp(b("CXR:") + " Prominent pulmonary arteries, RV enlargement, oligemic lung fields"),
    bp(b("Management:") + " Treat underlying cause, long-term O2 (LTOT if PaO2 <55 mmHg), diuretics for edema, phlebotomy if polycythemia, vasodilators in primary PHT"),
])
story.append(br())
story.append(hline())

# ── 1.7 RHEUMATIC FEVER ──────────────────────────────────────────────────
story.append(head("1.7  Rheumatic Fever - Jones Criteria  ⭐⭐⭐"))
story.append(warn_box("Appeared directly in Paper 1. Very likely to repeat as short note."))
story.append(br())
story.append(subh("Major Criteria  -  Mnemonic: SPACE"))
major = [
    ["S", "Sydenham's Chorea", "Involuntary, purposeless movements; emotional lability; 'milk maid grip'"],
    ["P", "Pancarditis (Carditis)", "Most serious - all 3 layers; new murmur, pericardial rub, cardiac enlargement, CCF"],
    ["A", "Arthritis (migratory)", "Large joints, fleeting, extremely painful, responds dramatically to aspirin"],
    ["C", "subcutaneous nodules", "Firm, painless, over bony prominences (elbows, wrists, occiput)"],
    ["E", "Erythema marginatum", "Serpiginous rash on trunk, pink border, central clearing, non-pruritic"],
]
story.append(simple_table(["Letter","Criterion","Description"], major, [1.5*cm, 5*cm, 10.5*cm]))
story.append(br())
story.append(subh("Minor Criteria"))
story.extend([
    bp("Fever > 38°C"),
    bp("Elevated ESR or CRP"),
    bp("Prolonged PR interval on ECG"),
    bp("Arthralgia (only if arthritis NOT used as major criterion)"),
])
story.append(br())
story.append(subh("Evidence of Preceding Strep Infection (MANDATORY)"))
story.extend([
    bp("Positive throat culture or rapid strep antigen test"),
    bp("Elevated or rising ASO (antistreptolysin O) titre"),
    bp("Recent scarlet fever"),
])
story.append(br())
story.append(red_box("Diagnosis = 2 Major  OR  1 Major + 2 Minor  + evidence of preceding strep infection"))
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 2 — RESPIRATORY
# ════════════════════════════════════════════════════════════════════════════

story.append(chapter_banner("SECTION 2: RESPIRATORY",
    "TB · COPD · Pleural Effusion · Consolidation vs Collapse · Pneumothorax"))
story.append(br())

# ── 2.1 TUBERCULOSIS ──────────────────────────────────────────────────────
story.append(head("2.1  Pulmonary Tuberculosis  ⭐⭐⭐"))
story.append(subh("Symptoms (Classic)"))
story.extend([
    bp(b("Constitutional:") + " Fever (evening rise), night sweats, weight loss, anorexia, malaise"),
    bp(b("Respiratory:") + " Cough >2 weeks (initially dry, later productive), hemoptysis, chest pain, breathlessness (if effusion/pneumothorax)"),
])
story.append(subh("Clinical Signs"))
story.extend([
    bp("Right upper zone: dullness (consolidation/fibrosis), bronchial breathing, crackles, TVF increased"),
    bp("Post-primary TB predominantly involves upper lobes (higher O2 tension favours Mycobacterium growth)"),
])
story.append(subh("Investigations"))
story.extend([
    bp(b("Sputum CBNAAT (Xpert MTB/RIF):") + " Most important first test - detects TB + rifampicin resistance in <2 hours"),
    bp(b("CXR:") + " Upper lobe consolidation, cavitation, fibrosis, bilateral disease; Ghon complex in primary TB"),
    bp(b("Sputum AFB (ZN stain):") + " 3 consecutive early morning samples"),
    bp(b("IGRA (Quantiferon Gold):") + " Latent TB detection"),
    bp(b("Culture (LJ medium):") + " 4-8 weeks; gold standard for sensitivity testing"),
])
story.append(subh("NTEP Treatment Regimen (ATT)"))
story.append(simple_table(
    ["Category", "Regimen", "Duration"],
    [
        ["New PTB/EPTB", "2HRZE + 4HR (daily)", "6 months"],
        ["Severe EPTB (TB meningitis, spinal TB)", "2HRZE + 10HR", "12 months"],
        ["MDR-TB", "Bedaquiline + Linezolid + Cycloserine + Clofazimine + Levofloxacin", "18-24 months"],
    ], [4*cm, 9*cm, 4*cm]))
story.append(br())
story.append(hline())

# ── 2.2 COPD ─────────────────────────────────────────────────────────────
story.append(head("2.2  Chronic Obstructive Pulmonary Disease (COPD)  ⭐⭐"))
story.append(subh("Types: Pink Puffer vs Blue Bloater"))
pp = ["Type A (emphysema predominant)", "Thin, cachectic, pursed lip breathing", "Barrel chest, no cyanosis", "Normal PaO2, low PaCO2 (hyperventilating)", "No cor pulmonale early", "Hyperresonant percussion"]
bb = ["Type B (chronic bronchitis predominant)", "Obese, cyanotic ('blue')", "Productive cough, peripheral edema", "Low PaO2, high PaCO2 (hypoventilating)", "Early cor pulmonale, polycythemia", "Normal percussion"]
story.append(two_col_table(pp, bb, "Pink Puffer (Emphysema)", "Blue Bloater (Chronic Bronchitis)"))
story.append(br())
story.append(subh("Spirometry & GOLD Classification"))
story.extend([
    bp(b("Obstruction:") + " FEV1/FVC < 0.70 (post-bronchodilator) - obstructive pattern"),
    bp(b("GOLD 1:") + " FEV1 ≥ 80% predicted (mild)"),
    bp(b("GOLD 2:") + " FEV1 50-79% (moderate)"),
    bp(b("GOLD 3:") + " FEV1 30-49% (severe)"),
    bp(b("GOLD 4:") + " FEV1 < 30% (very severe)"),
])
story.append(subh("Management"))
story.extend([
    bp(b("Smoking cessation:") + " Single most important intervention"),
    bp(b("Bronchodilators:") + " SABA (salbutamol) PRN → LABA (formoterol) + LAMA (tiotropium)"),
    bp(b("ICS:") + " Add if frequent exacerbations or eosinophil count >300"),
    bp(b("Long-term O2 (LTOT):") + " PaO2 <55 mmHg or <60 mmHg with polycythemia/cor pulmonale; ≥15 hrs/day"),
    bp(b("Acute exacerbation:") + " Controlled O2 (target SpO2 88-92%), nebulised SABA+SAMA, systemic steroids (prednisolone 40mg x 5 days), antibiotics if purulent sputum (amoxicillin/doxycycline), NIV if type 2 respiratory failure"),
])
story.append(br())
story.append(hline())

# ── 2.3 PLEURAL EFFUSION ──────────────────────────────────────────────────
story.append(head("2.3  Pleural Effusion - Clinical Examination  ⭐⭐⭐"))
story.append(subh("Right-sided Pleural Effusion - Examination Findings"))
story.extend([
    bp(b("Inspection:") + " Reduced chest expansion right side, fullness of intercostal spaces"),
    bp(b("Trachea:") + " Central (small-moderate) or shifted LEFT (massive - pushed away by fluid)"),
    bp(b("Palpation:") + " Reduced/absent TVF on right; reduced expansion"),
    bp(b("Percussion:") + " Stony dull (absolute dullness - unlike consolidation which is just dull)"),
    bp(b("Auscultation:") + " Absent breath sounds over effusion"),
    sbp("Upper border: Bronchial breathing (Skodaic resonance) + Aegophony ('E' → 'A' change)"),
    sbp("Grocco's triangle: area of dullness on opposite side near spine"),
])
story.append(br())
story.append(subh("Exudate vs Transudate (Light's Criteria)"))
story.append(info_box(
    b("Exudate if ANY ONE of: ") +
    "Pleural fluid protein/serum protein >0.5  |  "
    "Pleural fluid LDH/serum LDH >0.6  |  "
    "Pleural fluid LDH > 2/3 upper limit of normal serum LDH", LIGHT_GOLD, GOLD))
story.append(br())
exudate = ["Pneumonia (parapneumonic)", "TB pleural effusion", "Malignancy", "Pulmonary embolism", "Mesothelioma", "RA/SLE"]
transudate = ["Congestive cardiac failure (most common)", "Cirrhosis of liver", "Nephrotic syndrome", "Hypothyroidism", "Hypoalbuminemia"]
story.append(two_col_table(exudate + [""]*(len(transudate)-len(exudate)) if len(exudate)<len(transudate) else exudate,
    transudate + [""]*(len(exudate)-len(transudate)) if len(transudate)<len(exudate) else transudate,
    "Exudate", "Transudate"))
story.append(br())
story.append(hline())

# ── 2.4 CONSOLIDATION vs COLLAPSE ────────────────────────────────────────
story.append(head("2.4  Consolidation vs Collapse  ⭐⭐⭐"))
story.append(warn_box("Appeared as short essay in Paper 2 - comparing right upper lobe consolidation vs left upper lobe collapse."))
story.append(br())
c_headers = ["Feature", "Consolidation", "Collapse"]
c_rows = [
    ["Mechanism", "Air spaces filled with fluid/exudate (lung volume preserved)", "Loss of lung volume (airway obstruction or external compression)"],
    ["Mediastinum", "Central", "Shifted TOWARDS the lesion"],
    ["Trachea", "Central", "Pulled TOWARDS the lesion"],
    ["Expansion", "Reduced ipsilateral", "Reduced ipsilateral"],
    ["TVF/VR", "Increased (fluid conducts sound)", "Decreased (no air to transmit)"],
    ["Percussion", "Dull", "Dull"],
    ["Breath sounds", "Bronchial breathing", "Diminished/absent"],
    ["Added sounds", "Fine crackles", "Absent"],
    ["CXR", "Homogeneous opacity, air bronchogram", "Lobar opacity, mediastinal shift, elevated diaphragm"],
]
story.append(simple_table(c_headers, c_rows, [4*cm, 6.5*cm, 6.5*cm]))
story.append(br())
story.append(hline())

# ── 2.5 PNEUMOTHORAX ─────────────────────────────────────────────────────
story.append(head("2.5  Pneumothorax  ⭐⭐"))
story.extend([
    bp(b("Types:") + " Spontaneous primary (tall thin young male, no lung disease), Secondary (COPD, asthma, TB, Marfan's), Tension (emergency)"),
    bp(b("Symptoms:") + " Sudden unilateral pleuritic chest pain, breathlessness"),
    bp(b("Signs:") + " Reduced movement, hyperresonant percussion, absent breath sounds; trachea shifted AWAY from lesion (in tension)"),
    bp(b("Tension pneumothorax:") + " Also: hypotension, tachycardia, raised JVP, tracheal deviation - do NOT wait for CXR → immediate needle decompression 2nd ICS MCL"),
    bp(b("CXR:") + " Absent lung markings with visible visceral pleural edge; lung collapsed towards hilum"),
    bp(b("Management:") + " Observation if small (<2cm rim); aspiration if >2cm; intercostal drain; VATS for recurrent"),
])
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 3 — NEUROLOGY
# ════════════════════════════════════════════════════════════════════════════

story.append(chapter_banner("SECTION 3: NEUROLOGY",
    "UMN vs LMN · Stroke · Lateral Medullary · GBS · Aphasia · Meningitis"))
story.append(br())

# ── 3.1 UMN vs LMN ───────────────────────────────────────────────────────
story.append(head("3.1  UMN vs LMN Lesion  ⭐⭐⭐"))
story.append(warn_box("Appeared in Paper 2 as short essay (LMN weakness both limbs). Must know comparison table."))
story.append(br())
story.append(simple_table(
    ["Feature", "UMN Lesion", "LMN Lesion"],
    [
        ["Tone",          "Spastic (increased; clasp-knife rigidity)", "Flaccid (decreased)"],
        ["Power",         "Reduced", "Reduced"],
        ["Reflexes",      "Hyperreflexia (brisk, exaggerated)", "Hyporeflexia / areflexia"],
        ["Plantar",       "Extensor (Babinski positive)", "Flexor (normal)"],
        ["Clonus",        "Present", "Absent"],
        ["Wasting",       "Absent or minimal (disuse)", "Marked (denervation atrophy)"],
        ["Fasciculations","Absent", "Present"],
        ["Site of lesion","Cortex, internal capsule, brainstem, spinal cord (above anterior horn)", "Anterior horn cell, nerve root, peripheral nerve, NMJ, muscle"],
        ["Examples",      "Stroke, SOL, MS, spinal cord compression", "GBS, polio, peripheral neuropathy, motor neuron disease"],
    ],
    [4*cm, 6.5*cm, 6.5*cm]
))
story.append(br())
story.append(hline())

# ── 3.2 ISCHEMIC STROKE ───────────────────────────────────────────────────
story.append(head("3.2  Ischemic Stroke  ⭐⭐⭐"))
story.append(subh("Vascular Territory Syndromes"))
story.append(simple_table(
    ["Territory", "Clinical Features"],
    [
        ["MCA (most common)", "Contralateral hemiplegia (face + arm > leg), hemisensory loss, homonymous hemianopia; Dominant: aphasia (Broca's/Wernicke's); Non-dominant: neglect, aprosodia"],
        ["ACA", "Contralateral leg > arm weakness, urinary incontinence, frontal lobe signs (abulia, grasp reflex)"],
        ["PCA", "Contralateral homonymous hemianopia (with macular sparing), alexia without agraphia (dominant), prosopagnosia"],
        ["Vertebrobasilar", "Diplopia, dysphagia, dysarthria, ataxia, vertigo, crossed deficits (ipsilateral cranial nerve + contralateral limb)"],
        ["Lacunar", "Pure motor hemiplegia, pure sensory stroke, ataxic hemiparesis, clumsy hand-dysarthria syndrome"],
    ],
    [4*cm, 13*cm]))
story.append(br())
story.append(subh("Acute Management"))
story.extend([
    bp(b("CT head (non-contrast):") + " First investigation - exclude hemorrhage before thrombolysis"),
    bp(b("IV tPA (alteplase):") + " Within 4.5 hours of onset, BP <185/110, no contraindications"),
    bp(b("Mechanical thrombectomy:") + " Large vessel occlusion, within 6-24 hours (DAWN/DEFUSE criteria)"),
    bp(b("Aspirin 300mg:") + " If tPA not given; start within 48 hours"),
    bp(b("Target BP:") + " Allow permissive hypertension up to 220/120 in first 24 hrs (unless tPA given → <185/110)"),
])
story.append(subh("Secondary Prevention"))
story.extend([
    bp("Antiplatelet: aspirin + clopidogrel (dual) for 21 days, then single agent"),
    bp("Anticoagulation: if AF (cause of cardioembolic stroke)"),
    bp("Statin: high-intensity (atorvastatin 80mg) regardless of cholesterol level"),
    bp("BP control: start antihypertensives after acute phase (24-72 hrs)"),
])
story.append(br())
story.append(hline())

# ── 3.3 LATERAL MEDULLARY SYNDROME ───────────────────────────────────────
story.append(head("3.3  Lateral Medullary (Wallenberg) Syndrome  ⭐⭐⭐"))
story.append(warn_box("Appeared in BOTH model papers as short note. Very high repeat probability."))
story.append(br())
story.append(info_box(b("Artery: ") + "PICA (posterior inferior cerebellar artery) or vertebral artery occlusion → infarction of lateral medulla", GREY_BG, MID_BLUE))
story.append(br())
story.append(subh("IPSILATERAL (same side as lesion)"))
story.extend([
    bp("Facial pain and temperature loss (V nerve nucleus/tract)"),
    bp("Horner's syndrome: ptosis, miosis, anhidrosis (descending sympathetic tract)"),
    bp("Ataxia, dysdiadochokinesia (inferior cerebellar peduncle)"),
    bp("Dysphagia, dysphonia, hiccups (IX, X nerve nuclei)"),
    bp("Nystagmus, vertigo (vestibular nuclei)"),
])
story.append(subh("CONTRALATERAL (opposite side of lesion)"))
story.extend([
    bp("Limb and trunk pain and temperature loss (spinothalamic tract) - NOT touch/vibration"),
    bp("Note: Motor power is PRESERVED (corticospinal tract is NOT involved)"),
])
story.append(br())
story.append(key_box("Classic cross: Face ipsilateral + Body contralateral loss of pain/temperature. Touch/vibration preserved throughout."))
story.append(br())
story.append(hline())

# ── 3.4 GUILLAIN-BARRE SYNDROME ──────────────────────────────────────────
story.append(head("3.4  Guillain-Barre Syndrome (GBS)  ⭐⭐"))
story.extend([
    bp(b("Definition:") + " Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) - immune-mediated peripheral nerve demyelination"),
    bp(b("Trigger:") + " Campylobacter jejuni (most common), CMV, EBV, Mycoplasma, COVID-19, vaccinations (rarely)"),
    bp(b("Clinical:") + " Ascending symmetrical LMN weakness starting from legs; areflexia; minimal sensory symptoms"),
    bp(b("Autonomic:") + " Arrhythmias, BP fluctuations, urinary retention, facial flushing"),
    bp(b("Respiratory:") + " Diaphragm involvement → respiratory failure (most dangerous complication)"),
    bp(b("CSF:") + " Albuminocytological dissociation - high protein with normal cell count (after 1 week)"),
    bp(b("NCS/EMG:") + " Reduced conduction velocity, conduction block (demyelination)"),
    bp(b("Treatment:") + " IV immunoglobulin (IVIG) 0.4 g/kg x 5 days  OR  plasmapheresis; steroids NOT effective in AIDP"),
    bp(b("Monitor:") + " Regular spirometry (FVC <20 mL/kg → elective intubation)"),
])
story.append(br())
story.append(hline())

# ── 3.5 APHASIA vs DYSARTHRIA ────────────────────────────────────────────
story.append(head("3.5  Aphasia vs Dysarthria  ⭐⭐"))
story.append(warn_box("Appeared as short note in Paper 2. Two-mark setter."))
story.append(br())
story.append(two_col_table(
    ["Language processing disorder", "Dominant (left) hemisphere lesion", "Cortical/subcortical structures (Broca's or Wernicke's area)",
     "Comprehension affected OR expression affected", "Writing and reading also impaired", "Examples: Stroke in MCA territory"],
    ["Motor speech articulation disorder", "Cranial nerve / cerebellar / motor cortex lesion", "Can be bilateral or cerebellar",
     "Language content intact; only pronunciation affected", "Writing and reading NORMAL", "Examples: Cerebellar stroke, bulbar palsy, MND"],
    "Aphasia", "Dysarthria"
))
story.append(br())
story.append(subh("Types of Aphasia"))
story.append(simple_table(
    ["Type", "Fluency", "Comprehension", "Repetition", "Lesion"],
    [
        ["Broca's (Expressive)", "Non-fluent", "Intact", "Impaired", "Inferior frontal gyrus (Broca's area - BA44/45)"],
        ["Wernicke's (Receptive)", "Fluent (but paraphasias)", "Impaired", "Impaired", "Superior temporal gyrus (Wernicke's area - BA22)"],
        ["Global", "Non-fluent", "Impaired", "Impaired", "Large MCA territory infarct"],
        ["Conduction", "Fluent", "Intact", "Impaired", "Arcuate fasciculus"],
    ],
    [3.5*cm, 3*cm, 3.5*cm, 3*cm, 4*cm]))
story.append(br())
story.append(hline())

# ── 3.6 MENINGITIS ───────────────────────────────────────────────────────
story.append(head("3.6  Meningitis - Clinical Features  ⭐⭐"))
story.extend([
    bp(b("Classic triad:") + " Fever + Neck stiffness + Photophobia (± headache, altered consciousness)"),
    bp(b("Kernig's sign:") + " Patient supine, hip flexed 90°, pain/resistance on extending knee"),
    bp(b("Brudzinski's sign:") + " Passive neck flexion causes involuntary knee and hip flexion"),
    bp(b("Jolt accentuation:") + " Horizontal head rotation worsens headache; sensitive screening sign"),
    bp(b("CSF analysis:") + " LP after excluding raised ICP (CT head first if papilledema/focal deficit)"),
])
story.append(br())
story.append(simple_table(
    ["Parameter", "Normal", "Bacterial", "Viral", "TB"],
    [
        ["Appearance",   "Clear",    "Turbid/purulent", "Clear/slightly turbid", "Fibrin web/turbid"],
        ["Cells",        "<5 lymphs", "PMNs (>1000/mm³)", "Lymphocytes (<500)", "Lymphocytes (100-500)"],
        ["Protein",      "15-45 mg/dL", "Very high >100", "Normal/mildly raised", "High (100-500)"],
        ["Glucose",      "60-70% blood", "Very low (<45)", "Normal", "Very low (<45)"],
        ["Gram stain",   "-",        "Often positive", "Negative", "AFB in 20%"],
    ],
    [3*cm, 3*cm, 3.5*cm, 3.5*cm, 4*cm]))
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 4 — GI / HEPATOLOGY
# ════════════════════════════════════════════════════════════════════════════

story.append(chapter_banner("SECTION 4: GI / HEPATOLOGY",
    "Chronic Liver Disease · Jaundice · Ascites · Hepatic Encephalopathy"))
story.append(br())

# ── 4.1 CHRONIC LIVER DISEASE ────────────────────────────────────────────
story.append(head("4.1  Chronic Liver Disease - Clinical Examination  ⭐⭐⭐"))
story.append(warn_box("Appeared in BOTH model papers. Exam favourite. Know head-to-toe signs."))
story.append(br())
story.append(subh("Head-to-Toe Clinical Signs"))
cld_signs = [
    ["Hands", "Leukonychia (white nails), clubbing, palmar erythema (thenar/hypothenar), Dupuytren's contracture, asterixis (flapping tremor)"],
    ["Arms/Chest", "Spider naevi (>5 on upper body = significant; arterial, fills from centre), gynecomastia, sparse axillary hair"],
    ["Face/Eyes", "Jaundice (scleral icterus), parotid enlargement (alcoholic), fetor hepaticus, xanthelasma"],
    ["Abdomen", "Caput medusae (dilated periumbilical veins - portal HTN), splenomegaly, hepatomegaly (or small hard liver in cirrhosis), ascites (shifting dullness, fluid thrill)"],
    ["Genitalia", "Testicular atrophy (in males), gynaecomastia"],
    ["Legs", "Pedal edema (hypoalbuminemia + portal HTN), bruising (coagulopathy)"],
    ["Neurological", "Hepatic encephalopathy (grades 1-4), asterixis"],
]
story.append(simple_table(["Region", "Signs"], cld_signs, [4*cm, 13*cm]))
story.append(br())
story.append(subh("Child-Pugh Score"))
story.append(simple_table(
    ["Parameter", "1 point", "2 points", "3 points"],
    [
        ["Serum Bilirubin (mg/dL)", "<2", "2-3", ">3"],
        ["Serum Albumin (g/dL)", ">3.5", "2.8-3.5", "<2.8"],
        ["PT prolongation (secs)", "<4", "4-6", ">6"],
        ["Ascites", "None", "Mild (controlled)", "Moderate-severe"],
        ["Encephalopathy", "None", "Grade 1-2", "Grade 3-4"],
    ],
    [5*cm, 4*cm, 4*cm, 4*cm]))
story.append(info_box("Class A: 5-6 points (good prognosis)  |  Class B: 7-9 points  |  Class C: 10-15 points (poor prognosis)", LIGHT_GOLD, GOLD))
story.append(br())
story.append(hline())

# ── 4.2 JAUNDICE ─────────────────────────────────────────────────────────
story.append(head("4.2  Jaundice - Evaluation  ⭐⭐⭐"))
story.append(warn_box("Appeared in Paper 2 as short answer. Frequently tested."))
story.append(br())
story.append(simple_table(
    ["Parameter", "Pre-hepatic (Hemolytic)", "Hepatic (Hepatocellular)", "Post-hepatic (Obstructive)"],
    [
        ["Mechanism", "Excess bilirubin production", "Impaired conjugation/excretion", "Obstruction of bile flow"],
        ["Bilirubin type", "Unconjugated (indirect)", "Both (mixed)", "Conjugated (direct)"],
        ["Urine color", "Normal (urobilinogen only)", "Dark (bilirubin + urobilinogen)", "Dark (bilirubin; no urobilinogen)"],
        ["Stool color", "Normal/dark (urobilinogen)", "Pale (reduced)", "Pale/clay-colored"],
        ["Urine bilirubin", "Absent (indirect insoluble)", "Present", "Present"],
        ["Urine urobilinogen", "Increased", "Increased", "Absent"],
        ["LFT", "Normal AST/ALT", "High AST/ALT", "High ALP/GGT"],
        ["Spleen", "Enlarged", "Enlarged (portal HTN)", "Not enlarged"],
        ["Examples", "Malaria, G6PD, thalassemia, sickle cell", "Viral hepatitis, alcoholic hepatitis, drugs", "Gallstones, carcinoma head of pancreas, cholangiocarcinoma"],
    ],
    [4*cm, 4.3*cm, 4.3*cm, 4.4*cm]))
story.append(br())
story.append(hline())

# ── 4.3 ASCITES & SAAG ───────────────────────────────────────────────────
story.append(head("4.3  Ascites & SAAG  ⭐⭐⭐"))
story.append(warn_box("SAAG appeared directly in Paper 1 as short answer."))
story.append(br())
story.append(info_box(
    b("SAAG = Serum Albumin - Ascitic Fluid Albumin") +
    "<br/>SAAG ≥ 1.1 g/dL = Portal Hypertension (97% accuracy)<br/>"
    "SAAG < 1.1 g/dL = Non-portal hypertension cause", LIGHT_GREEN, GREEN))
story.append(br())
story.append(two_col_table(
    ["Cirrhosis (most common)", "CCF (cardiac ascites)", "Budd-Chiari syndrome", "Portal vein thrombosis", "Alcoholic hepatitis"],
    ["Peritoneal TB", "Peritoneal malignancy", "Pancreatitis", "Nephrotic syndrome", "Hypothyroidism"],
    "SAAG ≥ 1.1 (Portal HTN)", "SAAG < 1.1 (Non-portal)"
))
story.append(br())
story.append(subh("Clinical Examination for Ascites"))
story.extend([
    bp(b("Inspection:") + " Fullness of flanks, everted umbilicus, caput medusae, scrotal edema"),
    bp(b("Percussion:") + " Shifting dullness (detects >500 mL) - dull flanks, central resonant"),
    bp(b("Fluid thrill:") + " Large ascites (detects >1000 mL) - one hand on flank, assistant presses midline, tap other flank"),
])
story.append(br())
story.append(hline())

# ── 4.4 HEPATIC ENCEPHALOPATHY ───────────────────────────────────────────
story.append(head("4.4  Hepatic Encephalopathy  ⭐⭐"))
story.append(subh("Grading (West Haven Criteria)"))
story.append(simple_table(
    ["Grade", "Clinical Features"],
    [
        ["Grade 1", "Mild confusion, sleep disturbance, altered mood, impaired calculation"],
        ["Grade 2", "Drowsiness, asterixis (flapping tremor), inappropriate behaviour, disorientation"],
        ["Grade 3", "Somnolent but arousable, marked confusion, asterixis, rigidity"],
        ["Grade 4", "Coma (unresponsive), decorticate/decerebrate posturing"],
    ],
    [3*cm, 14*cm]))
story.append(br())
story.append(subh("Precipitating Factors - Mnemonic: ABCDEFG"))
story.extend([
    bp(b("A") + " - Azotemia (GI bleed, constipation)"),
    bp(b("B") + " - Benzodiazepines / sedatives"),
    bp(b("C") + " - Constipation"),
    bp(b("D") + " - Dietary protein excess"),
    bp(b("E") + " - Electrolyte imbalance (hypokalemia, hyponatremia)"),
    bp(b("F") + " - Fluid/Furosemide overuse (alkalosis)"),
    bp(b("G") + " - GI hemorrhage / infection / TIPS"),
])
story.append(br())
story.append(subh("Management"))
story.extend([
    bp("Identify and treat precipitating cause"),
    bp(b("Lactulose:") + " 30-60 mL 2-3 times daily; target 2-3 soft stools/day; traps ammonia as NH4+ in colon"),
    bp(b("Rifaximin:") + " 550 mg BD; non-absorbable antibiotic; reduces ammonia-producing gut bacteria"),
    bp(b("Dietary:") + " Adequate protein (do NOT restrict severely); branch chain amino acids if needed"),
    bp(b("Zinc supplementation:") + " Cofactor of urea cycle enzymes"),
])
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 5 — ENDOCRINE & RENAL
# ════════════════════════════════════════════════════════════════════════════

story.append(chapter_banner("SECTION 5: ENDOCRINE & RENAL",
    "Hypothyroidism · Diabetic Nephropathy · Nephrotic vs Nephritic · Hypertensive Emergency"))
story.append(br())

# ── 5.1 HYPOTHYROIDISM ────────────────────────────────────────────────────
story.append(head("5.1  Hypothyroidism  ⭐⭐⭐"))
story.append(subh("Clinical Features (System-wise)"))
hypo_features = [
    ["General", "Fatigue, weight gain (despite poor appetite), cold intolerance, dry coarse skin, non-pitting edema (myxedema - due to glycosaminoglycan accumulation)"],
    ["Face", "Puffy face, periorbital edema, coarse facial features, loss of outer 1/3 eyebrow (Hertoghe's sign), macroglossia"],
    ["CVS", "Bradycardia, low BP, pericardial effusion, muffled heart sounds"],
    ["Respiratory", "Pleural effusion, obstructive sleep apnea"],
    ["GI", "Constipation, ileus, ascites (rare)"],
    ["Neurological", "Slow relaxing reflexes (hung-up reflexes - pathognomonic!), carpal tunnel syndrome, cerebellar ataxia, psychosis (myxedema madness), coma"],
    ["Reproductive", "Menorrhagia (early), oligomenorrhea (late), infertility, galactorrhea (if hyperprolactinemia)"],
    ["Hematological", "Macrocytic or normocytic anemia"],
]
story.append(simple_table(["System", "Features"], hypo_features, [3*cm, 14*cm]))
story.append(br())
story.append(subh("Investigations & Management"))
story.extend([
    bp(b("TSH:") + " First line test; elevated in primary hypothyroidism (most common)"),
    bp(b("Free T4:") + " Low in overt hypothyroidism"),
    bp(b("TPO antibodies:") + " Elevated in Hashimoto's thyroiditis (autoimmune - most common cause)"),
    bp(b("Treatment:") + " Levothyroxine (T4) - start 25-50 mcg/day, increase by 25 mcg every 4-6 weeks; monitor TSH 6-8 weeks after each dose change; target TSH 0.5-2.5 mU/L"),
    bp(b("Myxedema coma:") + " IV T3 + IV hydrocortisone (may have coexisting adrenal insufficiency)"),
])
story.append(br())
story.append(hline())

# ── 5.2 DIABETIC NEPHROPATHY ─────────────────────────────────────────────
story.append(head("5.2  Diabetic Nephropathy  ⭐⭐"))
story.append(subh("Stages (Mogensen's Classification)"))
story.append(simple_table(
    ["Stage", "Description", "Urine Albumin", "GFR"],
    [
        ["Stage 1", "Hyperfiltration", "Normal", "Increased"],
        ["Stage 2", "Silent (normal urine)", "Normal", "Normal"],
        ["Stage 3", "Incipient DN (microalbuminuria)", "30-300 mg/day (ACR 30-300 mg/g)", "Normal/slightly reduced"],
        ["Stage 4", "Overt DN (macroalbuminuria)", ">300 mg/day", "Declining"],
        ["Stage 5", "ESRD", "Nephrotic range / declining", "<15 mL/min"],
    ],
    [2.5*cm, 5*cm, 5*cm, 4.5*cm]))
story.append(br())
story.append(subh("Management"))
story.extend([
    bp(b("Glycemic control:") + " HbA1c < 7% (individualize in elderly)"),
    bp(b("BP control:") + " Target <130/80 mmHg"),
    bp(b("ACE inhibitor/ARB:") + " First choice even without hypertension (reduce proteinuria, slow progression)"),
    bp(b("SGLT2 inhibitors:") + " Empagliflozin, dapagliflozin - reduce renal progression + CV mortality (now first-line with ACEi/ARB)"),
    bp(b("GLP-1 receptor agonists:") + " Semaglutide - additional renoprotection"),
    bp(b("Diet:") + " Protein restriction 0.8 g/kg/day"),
    bp(b("Renal replacement therapy:") + " Dialysis or transplant when eGFR <15"),
])
story.append(br())
story.append(hline())

# ── 5.3 NEPHROTIC vs NEPHRITIC ────────────────────────────────────────────
story.append(head("5.3  Nephrotic vs Nephritic Syndrome  ⭐⭐⭐"))
story.append(two_col_table(
    ["Proteinuria > 3.5 g/day", "Hypoalbuminemia < 3 g/dL", "Generalized edema (periorbital, ascites, pleural effusion)", "Hyperlipidemia + Lipiduria (fatty casts)", "BP usually normal initially",
     "Causes: MCD (children), FSGS (adults), membranous nephropathy (adults), diabetic nephropathy"],
    ["Hematuria (RBC casts - pathognomonic)", "Mild proteinuria (<3.5 g/day)", "Oliguria, hypertension, edema", "Azotemia (raised creatinine, urea)", "Hypertension prominent",
     "Causes: Post-strep GN (most common in children), IgA nephropathy, lupus nephritis, anti-GBM disease"],
    "Nephrotic Syndrome", "Nephritic Syndrome"
))
story.append(br())
story.append(key_box("Nephrotic = Protein loss. Nephritic = Blood (hematuria) + HTN. RBC casts = nephritic (GN)."))
story.append(br())
story.append(hline())

# ── 5.4 HYPERTENSIVE EMERGENCY ────────────────────────────────────────────
story.append(head("5.4  Hypertensive Emergency vs Urgency  ⭐⭐"))
story.append(two_col_table(
    ["BP >180/120 mmHg WITH end-organ damage", "Hypertensive encephalopathy", "Acute aortic dissection", "Acute pulmonary edema", "ACS (NSTEMI/unstable angina)", "Eclampsia / HELLP", "Acute kidney injury"],
    ["BP >180/120 mmHg WITHOUT end-organ damage", "Headache, anxiety only", "No neurological deficit", "No chest pain or pulmonary edema", "Stable patient", "Not pregnant / no complications", "Normal renal function"],
    "Hypertensive Emergency", "Hypertensive Urgency"
))
story.append(br())
story.append(subh("Management of Emergency"))
story.extend([
    bp(b("Rule:") + " Reduce MAP by no more than 25% in the first hour; then gradually to 160/100 over next 2-6 hrs"),
    bp(b("Exception:") + " Aortic dissection → reduce SBP to <120 mmHg within 20 minutes"),
    bp(b("Agents:") + " IV Labetalol (drug of choice, except asthma), IV Nicardipine, IV Sodium nitroprusside (most potent), IV Hydralazine (in eclampsia), IV GTN (if ACS/pulmonary edema)"),
    bp(b("Keith-Wagener-Barker Fundoscopic Grading:") + " Grade 1: Silver wiring | Grade 2: AV nipping | Grade 3: Flame hemorrhages + cotton wool spots | Grade 4: Papilledema"),
])
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 6 — CLINICAL SIGNS (SHORT ANSWERS)
# ════════════════════════════════════════════════════════════════════════════

story.append(chapter_banner("SECTION 6: CLINICAL SIGNS",
    "Short Answer Favourites - 2 Marks Each"))
story.append(br())

signs_data = [
    ("JVP - Normal Waveform",
     ["Waves: 'a' wave (atrial contraction), 'c' wave (tricuspid valve closure - often absent), 'x' descent (atrial relaxation + downward TV displacement), 'v' wave (venous filling while TV closed), 'y' descent (TV opens, blood drains into RV)",
      "Normal JVP: 1-8 cm above sternal angle; measured at 45° position",
      "Absent 'a' wave = Atrial fibrillation",
      "Giant 'a' wave = Tricuspid stenosis, pulmonary stenosis, pulmonary HTN",
      "Giant 'v' wave = Tricuspid regurgitation",
      "Kussmaul's sign: JVP rises on inspiration (constrictive pericarditis, RV infarction)"]),
    ("Third Heart Sound (S3)",
     ["Timing: Early diastole (after S2), low-pitched",
      "Best heard: Apex with bell, left lateral decubitus position",
      "Mechanism: Rapid ventricular filling causing vibration of ventricular walls",
      "Pathological S3: Heart failure (most important), MR, VSD, volume overload",
      "Physiological S3: Normal in children, young adults, pregnancy",
      "Together with S1 and S2: 'Kentucky' gallop rhythm"]),
    ("SAAG",
     ["SAAG = Serum Albumin minus Ascitic fluid Albumin",
      "SAAG ≥ 1.1: Portal hypertension (cirrhosis, CCF, Budd-Chiari, portal vein thrombosis)",
      "SAAG < 1.1: Non-portal hypertension (TB peritonitis, peritoneal malignancy, pancreatitis, nephrotic syndrome)",
      "Accuracy 97% in distinguishing cause of ascites"]),
    ("Babinski Sign / Plantar Response",
     ["Method: Stroke the lateral aspect of the sole from heel to ball of foot with an orange stick",
      "Normal (flexor): Plantar flexion of hallux + fanning of toes",
      "Abnormal (extensor/Babinski positive): Dorsiflexion of hallux + fanning of toes",
      "Significance: Positive Babinski = UMN lesion (pyramidal tract damage)",
      "Normal in infants up to 18 months (corticospinal tracts not yet myelinated)",
      "Other extensor plantar signs: Oppenheim, Gordon, Chaddock, Schaefer"]),
    ("Flapping Tremor (Asterixis)",
     ["Mechanism: NOT a true tremor; inability to maintain a sustained posture due to brief lapses in muscle contraction",
      "How to elicit: Wrists extended, fingers spread, arms outstretched → irregular flapping movements",
      "Causes: Hepatic encephalopathy (classic), CO2 narcosis (COPD type 2 failure), uremia, drug toxicity",
      "Bilateral = metabolic encephalopathy; Unilateral = contralateral thalamic lesion"]),
    ("Clubbing - Grading",
     ["Grade 1: Fluctuation/sponginess of nail bed (Schamroth sign - obliteration of diamond window)",
      "Grade 2: Loss/obliteration of nail fold angle (> 180°)",
      "Grade 3: Drumstick/parrot-beak appearance of fingertips",
      "Grade 4: Hypertrophic pulmonary osteoarthropathy (HPOA) - periosteal new bone formation",
      "Causes: Respiratory (lung carcinoma, bronchiectasis, lung abscess, ILD, TB, cystic fibrosis), Cardiac (cyanotic CHD, SBE), GI (IBD, cirrhosis, celiac disease)"]),
    ("Pulsus Paradoxus",
     ["Definition: Exaggerated fall in systolic BP >10 mmHg during inspiration",
      "Mechanism: On inspiration, negative intrathoracic pressure → increased RV filling → septum bows into LV → reduced LV output",
      "Causes: Cardiac tamponade (most important), severe asthma, COPD, tension pneumothorax, constrictive pericarditis (occasionally)",
      "Measurement: Inflate BP cuff above systolic, slowly deflate - first Korotkoff sounds heard only in expiration; continue deflating until heard throughout - difference = paradox"]),
    ("Osler's Nodes vs Janeway Lesions",
     ["Osler's Nodes: PAINFUL, raised, tender nodules on finger pads and toes; immune-complex mediated; transient (last days)",
      "Janeway Lesions: PAINLESS, flat, erythematous macules on palms and soles; septic emboli; persistent",
      "Both: Features of Infective Endocarditis (minor Duke criteria)",
      "Memory: Osler = Ouch (painful); Janeway = Just passing through (embolic, painless)"]),
    ("Glasgow Coma Scale (GCS)",
     ["Eyes: Spontaneous (4), To voice (3), To pain (2), None (1)",
      "Verbal: Oriented (5), Confused (4), Inappropriate words (3), Sounds (2), None (1)",
      "Motor: Obeys commands (6), Localizes (5), Withdraws (4), Flexion/decorticate (3), Extension/decerebrate (2), None (1)",
      "Maximum = 15; Minimum = 3",
      "GCS ≤ 8 = severe TBI, consider intubation",
      "GCS 9-12 = moderate; GCS 13-15 = mild TBI"]),
    ("Kernig's and Brudzinski's Signs",
     ["Kernig's: Patient supine, hip and knee flexed to 90°; attempt to extend the knee → pain and resistance = positive; (due to meningeal irritation of L3/L4 nerve roots)",
      "Brudzinski's neck sign: Passive flexion of neck → involuntary flexion of hips and knees",
      "Brudzinski's leg sign: Flexion of one hip → contralateral hip involuntarily flexes",
      "Significance: Meningitis (bacterial/viral/TB), subarachnoid hemorrhage",
      "Specificity > sensitivity - negative signs do NOT rule out meningitis"]),
    ("Cheyne-Stokes Respiration",
     ["Pattern: Cyclical waxing-waning depth of breathing with periods of apnea",
      "Mechanism: Hypersensitivity of respiratory centre to CO2; apnea → CO2 rises → hyperventilation → CO2 falls → apnea",
      "Causes: Severe CCF (most common), bilateral cerebral hemispheric disease, stroke, uremia, narcotic overdose, high altitude (Cheyne-Stokes of altitude is normal)",
      "Significance in CCF: Prolonged circulation time → delayed CO2 feedback to respiratory centre"]),
    ("Trousseau's and Chvostek's Signs",
     ["Trousseau's: Inflate BP cuff above systolic pressure for 3 minutes → carpal spasm (main d'accoucheur) = positive",
      "Chvostek's: Tap facial nerve just anterior to ear → ipsilateral facial muscle twitch = positive",
      "Both indicate: Hypocalcemia (latent tetany)",
      "Causes of hypocalcemia: Hypoparathyroidism (post-thyroidectomy most common), pseudohypoparathyroidism, vitamin D deficiency, acute pancreatitis, renal failure",
      "Trousseau's more specific; Chvostek's can be positive in 10-25% of normal individuals"]),
    ("Cyanosis - Central vs Peripheral",
     ["Central cyanosis: Bluish discolouration of lips, tongue, oral mucosa; SaO2 < 85%; WARM periphery",
      "Causes of central: Cardiac (R→L shunt - TOF, Eisenmenger), Respiratory (COPD, severe pneumonia, ARDS), High altitude, Methaemoglobinaemia",
      "Peripheral cyanosis: Bluish fingers/toes only; tongue pink; COLD periphery; normal SaO2",
      "Causes of peripheral: Cold exposure, shock, CCF (low CO), Raynaud's phenomenon, DVT",
      "Differential cyanosis: Lower limbs cyanosed, upper normal = PDA with reversal (Eisenmenger via PDA)"]),
    ("Virchow's Triad",
     ["Three components predisposing to venous thrombosis (DVT/PE):",
      "1. Stasis - immobility, CCF, prolonged travel, obesity",
      "2. Hypercoagulability - malignancy, factor V Leiden, protein C/S deficiency, antiphospholipid syndrome, OCP, pregnancy",
      "3. Endothelial injury - trauma, surgery, vasculitis, central venous catheters",
      "Clinical relevance: DVT → PE; Prophylaxis with LMWH in at-risk surgical/medical patients"]),
]

for sign_title, points in signs_data:
    content = [Paragraph(b(sign_title), section_head)]
    for pt in points:
        content.append(bp(pt))
    content.append(br())
    content.append(hline())
    story.extend(content)

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# FINAL PAGE — EXAM STRATEGY
# ════════════════════════════════════════════════════════════════════════════

story.append(chapter_banner("EXAM STRATEGY & QUICK REVISION", "Last-minute tips and priority topics"))
story.append(br())

story.append(head("Priority Matrix"))
story.append(simple_table(
    ["Priority", "Topic", "Format", "Marks"],
    [
        ["⭐⭐⭐ MUST",  "Mitral Stenosis / Aortic Regurgitation",     "Essay",       "10"],
        ["⭐⭐⭐ MUST",  "Chronic Liver Disease - clinical signs",       "Short Essay",  "6"],
        ["⭐⭐⭐ MUST",  "Rheumatic Fever - Jones Criteria",            "Short Essay",  "6"],
        ["⭐⭐⭐ MUST",  "Cor Pulmonale",                               "Short Essay",  "6"],
        ["⭐⭐⭐ MUST",  "Consolidation vs Collapse",                    "Short Essay",  "6"],
        ["⭐⭐⭐ MUST",  "UMN vs LMN comparison",                       "Short Essay",  "6"],
        ["⭐⭐⭐ MUST",  "Ischemic stroke management",                  "Short Essay",  "6"],
        ["⭐⭐⭐ MUST",  "JVP waveform (draw and label)",               "Short Answer", "2"],
        ["⭐⭐⭐ MUST",  "SAAG interpretation",                         "Short Answer", "2"],
        ["⭐⭐⭐ MUST",  "Lateral Medullary Syndrome",                  "Short Answer", "2"],
        ["⭐⭐   HIGH",  "CCF - left vs right features",                "Short Essay",  "6"],
        ["⭐⭐   HIGH",  "Infective Endocarditis - Duke criteria",      "Short Essay",  "6"],
        ["⭐⭐   HIGH",  "COPD - management",                           "Short Essay",  "6"],
        ["⭐⭐   HIGH",  "GBS - clinical + CSF + treatment",            "Short Essay",  "6"],
        ["⭐⭐   HIGH",  "Babinski sign / plantar response",            "Short Answer", "2"],
        ["⭐⭐   HIGH",  "Aphasia vs dysarthria",                       "Short Answer", "2"],
        ["⭐⭐   HIGH",  "Flapping tremor / asterixis",                 "Short Answer", "2"],
        ["⭐⭐   HIGH",  "Jaundice - types comparison",                 "Short Answer", "2"],
    ],
    [2.5*cm, 7*cm, 3.5*cm, 2*cm]
))
story.append(br())

story.append(head("Essay Answer Framework"))
story.append(info_box(
    b("For ANY cardiac case vignette, answer subparts in this order:<br/>")
    + "a) Diagnosis: Name the condition + supporting evidence from vignette + 2-3 differentials<br/>"
    + "b) CVS exam: Inspection → Palpation → Auscultation (use named signs)<br/>"
    + "c) Investigations: ECG findings + CXR findings + Echo findings (be specific)<br/>"
    + "d) Complications/Worsening: Name the most common complication first (usually AF in MS)",
    LIGHT_BLUE, MID_BLUE
))
story.append(br())

story.append(head("Marks-Scoring Tips"))
story.extend([
    bp("Use named eponyms: examiners love named signs (Corrigan's, De Musset's, Duroziez's, etc.)"),
    bp("For short notes: Write in structured format - Definition / Causes / Clinical features / Investigations / Management"),
    bp("For comparison questions (consolidation vs collapse, UMN vs LMN): Use a table format"),
    bp("For Jones criteria, always mention: 2 major OR 1 major + 2 minor + STREP evidence"),
    bp("Draw JVP waveform clearly with labeled a, c, x, v, y components"),
    bp("SAAG formula: Write it out first, then interpret ≥1.1 and <1.1"),
    bp("In neurology cases: State which side is ipsilateral vs contralateral to lesion"),
])
story.append(br())
story.append(key_box("Good luck with your exam! Focus on Cardiology first (40% of exam), then Respiratory and Neurology."))

# ── BUILD ────────────────────────────────────────────────────────────────────

def add_page_number(canvas, doc):
    canvas.saveState()
    canvas.setFont("Helvetica", 8)
    canvas.setFillColor(colors.HexColor("#64748b"))
    canvas.drawString(2*cm, 1.2*cm, "General Medicine End Posting Study Guide  |  2023 Batch Phase 3 Part 1  |  Govt. Medical College, Manjeri")
    canvas.drawRightString(19*cm, 1.2*cm, f"Page {doc.page}")
    canvas.restoreState()

doc.build(story, onFirstPage=add_page_number, onLaterPages=add_page_number)
print(f"PDF saved to: {OUTPUT}")